Failure to Update Mobility Care Plan to Match Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s mobility care plan to reflect a current physician’s order. The resident had diagnoses including osteoarthritis of the knee, rheumatoid arthritis, and generalized anxiety disorder, and had a BIMS score of 12/15 indicating some memory recall deficits. A physician’s order dated 3/2/25, and still current, directed that the resident receive bed mobility assistance of two and transfer assistance of two with a rolling walker. The annual MDS identified that the resident required partial assistance with bed mobility and transfers and used a wheelchair for mobility. However, the Resident Care Plan initiated on 1/6/24 and last reviewed on 1/16/26 identified the resident as requiring assistance with mobility due to decreased strength and listed interventions indicating the resident was a total lift for transfers, which did not match the physician’s order. Interviews and record reviews confirmed that the care plan had not been updated despite changes in the resident’s mobility status and existing orders. The PT and OT reported that the resident had been on therapy services until 12/18/25 and was discharged at that time as an assist of two for stand-pivot transfers between bed and wheelchair, consistent with the 3/2/25 activity orders. They stated they would have notified the charge nurse of the resident’s transfer status and that therapy staff do not update care plans, leaving that responsibility to nursing. They acknowledged the mobility care plan last reviewed on 1/16/26 was incorrect and that the resident had not required a total lift for transfers since 3/2025. The DON confirmed that the mobility care plan should have matched the 3/2/25 physician’s order and that both the IDT and the MDS nurse were responsible for reviewing and revising care plans, including during care plan meetings. The facility’s Comprehensive Care Planning policy directed that care plans be revised as residents’ conditions change and be reviewed and updated at significant changes and at least quarterly, but this was not done for this resident’s mobility care plan.
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